Phillip Waite
Final Paper: Value‐based Care and the Physician
The change to a value‐based system of healthcare reimbursement is something that I find rather daunting and somewhat scary. The traditional fee‐for‐service system, with all of its flaws, was quite simple to understand—you pay for the care that is given and if you don’t want to pay more, take care of yourself outside of the physician’s office. But, I guess my fear and apprehension about value‐based reimbursement have their foundation in not fully understanding the change and not being able to foresee its impact far into the future. Now, nobody can predict the future, but as I’ve come to find out, that plays a big role in remaining profitable in a value‐based system.
Despite my initial thoughts on moving from a fee‐for‐service system, I’ve come to believe that it is the right move, insomuch as it is forcing providers and organizations to focus on preventative care for their patients. Under a fee‐for‐service model, healthcare organizations and providers profited from the ailments of their patients. More procedures meant more money. Less and less thought was given to prevention because it wasn’t profitable. This is one of the factors that has led to an increase in healthcare costs over the years.1 Under a value‐based system, the physicians and organizations are incentivized to improve quality of care delivery and cut costs. The Centers for Medicare & Medicaid
Services (CMS) has indicated that there needs to be more focus on primary care and primary care providers.2 By having more interaction with a primary care provider and having the primary care provider actively managing the health of patients, unexpected hospitalizations and emergency room visits—both of which are extremely costly—should decrease. It is the hope that any issues requiring hospitalization might be caught early and handled in an outpatient or ambulatory setting.
Having the primary care provider more involved in managing patient health makes logical sense.
Moreover, it sounds like it should cut costs and provide patients with better care. But, from where are those primary care provider going to come? New physicians enter the workforce at an almost steady rate of 26,000/year. Medical schools have a difficult time increasing class sizes and the number of residencies each year is pretty fixed. Efforts are being made to increase the number of residency programs in the United States, but it is predicted that by 2020, the United States will face a shortage of
90,000 physicians.3 Moreover, as the population ages, more specialty physicians will be needed, leaving the pool of physicians that are primary care providers even smaller. So, we need to increase the number of primary care providers while already facing a shortage of physicians. Despite the dire circumstances of physician shortages, there are many opportunities to be considered that might improve patient access to not just primary care, but sometimes specialty care as well.
The first possibility would be to continue to change the mix of primary care providers. Not all primary care providers need to be physicians or even more specifically, M.D.’s. There are more and more doctors of osteopathic medicine (D.O.) in the workforce than in the past. They might still face residency programs issues, but they have been a boon to the physician workforce in recent years. Aside from

physicians—M.D. or D.O.—there are physician assistants (PAs) and nurse practitioners (NPs) that could be utilized. Neither PAs nor NPs can practice on their own, but they can practice under the direction of a certified physician. Both PAs and NPs have shorter educational and training requirements and could therefore be put into the workforce much more quickly. For PAs, the projected demand was expected to increase by 38% from 2012 to 2022.4 But they continue to face a similar problem to that of physicians—there are not enough sites for PAs to get clinical rotations. But, if PAs and NPs could be utilized more in the primary care setting they could improve patient access to primary care providers and continue to cut costs by managing whole patient care.
Along with giving more freedom to PAs and NPs to practice, telehealth is becoming an increasingly more popular option. It seemed like ages since technology companies had commercials touting the ability of physicians and patients to connect across long distances in real time to treat patients. But those commercials are finally becoming reality. Telehealth continues to grow, to the point that it is now sometimes the norm or is expected to be included in health plans for enrollees. Research indicates that access to telemedicine will continue to grow at a rate of 18‐30% per year.5 It has continued to grow in popularity among users and it is a cost savings for plan providers. In a 2014 survey, 37% of employers indicated that they would be adding a telemedicine benefit in the next year.6 Patients are pleased with it because it provides easy, high‐quality access to care without having to actually go to the primary care provider. It generally has low to no wait times, thereby getting an answer to the patient more quickly.
Some providers like the fact that they can do it from home or another local other than the office. This allows them to be reachable at odd hours or on the weekends, when the patient might have otherwise just gone to the emergency room. This improves the quality of life for the primary care provider, allowing them to be flexible in working hours and telecommuting.
Telehealth also has benefits beyond access to primary care providers. For example, the University of
Utah has a telemedicine program called Telestroke that partners with hospitals as far away as Grand
Junction, CO and Ely, NV. This allows the benefits of specialized physicians—that operate in communities that have a high demand for their specialty and allow extensive experience—to service patients in smaller communities whose population size doesn’t warrant a stroke program. It is easy to see the benefits of telemedicine in preventative healthcare management reaching rural or more remote areas of the country. Those individuals could have the benefit of personalized and managed care living in a remote setting.
Under the provisions of the Health Information Technology for Economic and Clinical Health (HITECH)
Act, physicians have an increased burden of administrative duties that they haven’t had in the past. I had the opportunity to speak with Mark Moody. He is the Assistant Regional Operations Officer in the
Intermountain Medical Group. He deals a lot with physicians and physician group in his role. In our conversation, he spoke of the difficulty that he has in getting compliance from his physicians with regards to meaningful use and the electronic health record technology mandates. Mark related a conversation he’d had with a physician in which the physician indicated feeling more like a secretary

that a doctor. But, in order to qualify for Medicaid and Medicare reimbursement, it is necessary to comply with meaningful use and having electronic medical records. I asked if younger physicians were more understanding this extra work and he said that that was definitely the case. This is such a shift in how things are done, that it’s no surprise to hear that older physicians, more entrenched in their ways, are less amenable to this type of change. However, providers who failed to comply with and meet the meaningful use standards by the year 2015 would have been met with penalties under the HITECH Act, making it difficult not to comply.
With all of the shortages on physicians and physician time, it would therefore make sense to alleviate some of this administrative burden being placed on them. Under one of the core objectives of meaningful use, credentialed medical assistants are permitted to use the Computerized Physician Order
Entry system to enter orders for medications and radiology and laboratory services.7 If providers are not already using credentialed medical assistants to help with this type of data entry, they should be.
Beyond what is already allowed, perhaps methods can be adopted and approved that extend these administrative duties to yet others. It would further decrease the burden on physicians if more of these meaningful use duties could be passed on to others.
As I alluded to in the first paragraph, the ability of providers and organizations to be profitable in a value‐based system depends on their being able to predict the future. Their reimbursements are based on how much it cost to treat patients in the past, but they have to plan for each year trying to determine what their costs are going to be for that year. But, one thing that is sure to help keep these costs down is the role of the primary care provider in managing these patients’ care. The difficulties of a value‐ based system can be overcome and will ultimately benefit the patients in the long run, but we need to find ways to keep primary care providers involved in the care. References:
1. The Power of Prevention. CDC. 2009. Web. Feb 15, 2016. http://www.cdc.gov/
2. Sederstrom, Jill. “7 Ways to Improve Access.” May 30, 2014. Web. Feb 17, 2016. http://managedhealthcareexecutive.modernmedicine.com/ 3. Bernstein, Lenny. “U.S. Faces 90,000 Doctor Shortage by 2025, Medical School Association
Warns.” Mar 3, 2015. Web. Feb 13, 2016. https://www.washingtonpost.com/
4. Anglebrandt, Gary. “Physician Assistant’s Paradox: Despite Interest, Demand There’s Dearth of
Training Slots.” Aug 3, 2014. Web. Feb 13, 2016 http://www.crainsdetroit.com/
5. Ken Research, “The US Telemedicine Market Outlook to 2018, Rising Penetration of Telehome
Care and Health.” June 2014
6. “Current Telemedicine Technology Could Mean Big Savings.” Aug 11, 2014. Web. Feb 17,
2016. http://www.towerswatson.com/
7. “Credentialed Medical Assistants Aid in Meaningful Use Compliance and Increase Office
Efficiency.” Web. Feb 15, 2016. http://www.americanmedtech.org/